DOB: NHSno:
Pan London Suspected Children's Cancer Referral Form
(patients aged under 16 yrs)
Press the <Ctrl> key while you click here to view the Pan London Suspected Cancer Referral Support Guide
Pan London Suspected Children's Cancer Referral Form Page 1 of 4
(Version: Pan London changes SONI v1.0; 12/04/2016)
DOB: NHSno:
REFERRALDATE:«Todays_date»
Pan London Suspected Children's Cancer Referral Form Page 1 of 4
(Version: Pan London changes SONI v1.0; 12/04/2016)
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_Name»
The GP MUST ALWAYS discuss the patient with the local paediatrician on call and refer the patient to the paediatric department for an appointment within 48 hours.
Suspected Retinoblastoma: Use Pan London Suspected Lid, Orbital, Retinoblastoma & Conjunctival Cancer Referral Form
Suspected Skin Cancer: Use Pan London Suspected Skin Cancer Referral Form
Suspected Bone Sarcoma: Use Pan London and South East Network Suspected Sarcoma Referral Form
Press the <Ctrl> key while you click here to view Pan London Suspected Sarcoma Referral Guide
Please email or send e-referral within 24 hours.
Fax is no longer supported due to patient safety and confidentiality risks.
Press the <Ctrl> key while you click here to view the list of hospitals you can refer to
Copy the hospital details from the webpage and paste them onto the line below.
PATIENT DETAILS
Pan London Suspected Children's Cancer Referral Form Page 4 of 4
(Version: Pan London changes SONI2; 13/01/2016)
Standard NHS Referral Form Layout & Artwork created by Dr Ian Rubenstein
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_Name»
SURNAME:«Surname» FIRSTNAME:«Forename» TITLE:«Title»
GENDER:«Gender» DOB:«Date_of_birth» AGE:«Patient_Age» NHSNO:«NHS_number»
ETHNICITY:«Ethnicity» LANGUAGE:«Main_spoken_language»
Pan London Suspected Children's Cancer Referral Form Page 4 of 4
(Version: Pan London changes SONI2; 13/01/2016)
Standard NHS Referral Form Layout & Artwork created by Dr Ian Rubenstein
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_Name»
INTERPRETER REQUIRED TRANSPORT REQUIRED
Pan London Suspected Children's Cancer Referral Form Page 4 of 4
(Version: Pan London changes SONI2; 13/01/2016)
Standard NHS Referral Form Layout & Artwork created by Dr Ian Rubenstein
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_Name»
PATIENTADDRESS:«Patient_address__single_line»
Pan London Suspected Children's Cancer Referral Form Page 4 of 4
(Version: Pan London changes SONI2; 13/01/2016)
Standard NHS Referral Form Layout & Artwork created by Dr Ian Rubenstein
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_Name»
DAYTIMECONTACT':
Pan London Suspected Children's Cancer Referral Form Page 4 of 4
(Version: Pan London changes SONI2; 13/01/2016)
Standard NHS Referral Form Layout & Artwork created by Dr Ian Rubenstein
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_Name»
HOME':«Patient_home_telephone_number» MOBILE':«Patient_mobile_telephone_number» WORK':«Patient_alternate_telephone_number»
Pan London Suspected Children's Cancer Referral Form Page 4 of 4
(Version: Pan London changes SONI2; 13/01/2016)
Standard NHS Referral Form Layout & Artwork created by Dr Ian Rubenstein
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_Name»
EMAIL:
Pan London Suspected Children's Cancer Referral Form Page 4 of 4
(Version: Pan London changes SONI2; 13/01/2016)
Standard NHS Referral Form Layout & Artwork created by Dr Ian Rubenstein
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_Name»
CARER/KEY WORKER DETAILS
Pan London Suspected Children's Cancer Referral Form Page 4 of 4
(Version: Pan London changes SONI2; 13/01/2016)
Standard NHS Referral Form Layout & Artwork created by Dr Ian Rubenstein
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_Name»
NAME: CONTACT': RELATIONSHIP TO PATIENT:
COGNITIVE, SENSORY OR MOBILITY IMPAIRMENT
COGNITIVE SENSORY MOBILITY DISABLED ACCESS REQUIRED
Pan London Suspected Children's Cancer Referral Form Page 4 of 4
(Version: Pan London changes SONI2; 13/01/2016)
Standard NHS Referral Form Layout & Artwork created by Dr Ian Rubenstein
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_Name»
PLEASE INCLUDE RELEVANT DETAILS:
SAFEGUARDING
SAFEGUARDING CONCERNS
PLEASE INCLUDE RELEVANT DETAILS:
Pan London Suspected Children's Cancer Referral Form Page 4 of 4
(Version: Pan London changes SONI2; 13/01/2016)
Standard NHS Referral Form Layout & Artwork created by Dr Ian Rubenstein
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_Name»
GP DETAILS
USUALGPNAME:«Usual_doctor»
PRACTICENAME:«Sender_organisation_name» PRACTICE CODE:«Registered_GP_practice_ID»
Pan London Suspected Children's Cancer Referral Form Page 4 of 4
(Version: Pan London changes SONI2; 13/01/2016)
Standard NHS Referral Form Layout & Artwork created by Dr Ian Rubenstein
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_Name»
PRACTICEADDRESS:«Sender_address_building», «Sender_address_road», «Sender_address_locality», «Sender_address_post_town», «Sender_address_county», «Sender_post_code»
Pan London Suspected Children's Cancer Referral Form Page 4 of 4
(Version: Pan London changes SONI2; 13/01/2016)
Standard NHS Referral Form Layout & Artwork created by Dr Ian Rubenstein
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_Name»
BYPASS':
MAIN':«Registered_GP_phone_number» FAX:«Registered_GP_fax_number» EMAIL:
Pan London Suspected Children's Cancer Referral Form Page 4 of 4
(Version: Pan London changes SONI2; 13/01/2016)
Standard NHS Referral Form Layout & Artwork created by Dr Ian Rubenstein
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_Name»
REFERRINGCLINICIAN:«Sender_name»
Pan London Suspected Children's Cancer Referral Form Page 4 of 4
(Version: Pan London changes SONI2; 13/01/2016)
Standard NHS Referral Form Layout & Artwork created by Dr Ian Rubenstein
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_Name»
Pan London Suspected Children's Cancer Referral Form Page 4 of 4
(Version: Pan London changes SONI2; 13/01/2016)
Standard NHS Referral Form Layout & Artwork created by Dr Ian Rubenstein
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_Name»
CANCER TYPE SUSPECTEDLeukaemia / Lymphoma / Brain Tumour
Soft Tissue Sarcoma / Hepatoblastoma / Wilm’s Tumour
Neuroblastoma / Unknown
REASON FOR SUSPECTED CANCER REFERRAL
Children should be seen by a specialist WITHIN 48 HOURS.
Refer children and young people for IMMEDIATE SPECIALIST ASSESSMENT for leukaemia if they have unexplained petechiae or hepatosplenomegaly or if the results of a full blood count are suggestive of leukaemia.
Press the <Ctrl> key while you click here to view Pan London Suspected Children’s Cancer Referral Guide
CLINICAL FEATURES
General
Weight loss / Fatigue/malaise/lethargy
Appetite loss / Nausea/vomiting
Unexplained fever / Night sweats
Unexplained pruritus / Unexplained persistent infection
Shortness of breath / Pallor or other signs of anaemia
Pain
Bone pain / Abdominal pain / Unexplained headache
Urology
Unexplained visible haematuria
Neurology
Fits / Weakness / Dysphagia
Ataxia / Torticollis / Facial nerve weakness
Behavioural change or deterioration in developmental milestones/school performance
Soft tissue sarcoma
Unexplained soft tissue lump
Increasing in size / Deep to fascia / Fixed/immobile
Painful / 5cm in size
Pan London Suspected Children's Cancer Referral Form Page 4 of 4
(Version: Pan London changes SONI2; 13/01/2016)
Standard NHS Referral Form Layout & Artwork created by Dr Ian Rubenstein
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_Name»
EXAMINATIONSkin lesions/oedema / Abdominal mass / Soft tissue mass
Chest signs / Splenomegaly / Hepatomegaly
Unexplained lymphadenopathy / Nerve palsy / Unexplained bruising
Referral is due to CLINICAL CONCERNS that do not meet NICE/pan-London referral criteria (the GP MUST give full clinical details in the ‘additional clinical information’ box at time of referral)
Pan London Suspected Children's Cancer Referral Form Page 4 of 4
(Version: Pan London changes SONI2; 13/01/2016)
Standard NHS Referral Form Layout & Artwork created by Dr Ian Rubenstein
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_Name»
Additional clinical information:
Personal/relevant patient information:
Past history of cancer:
Relevant family history of cancer:
I have discussed the possible diagnosis of cancer with the patient/guardianThe patient/guardian has been advised and confirmed they will be available for an appointment within 48 hours
I have counselled the patient/guardian regarding the referral process and offered the pan-London information leaflet. Offering written patient information increases patient experience and reduces non-attendance. These are available in 11 different languages.
Press the <Ctrl> key while you click here to view the leaflet
This patient has been added to the practice suspected cancer safety-netting system
Press the <Ctrl> key while you click here to view Pan London Practice-based Suspected Cancer Safety Netting System
INVESTIGATIONS
Please ensure this referral includes ALL the relevant investigations including blood tests and imaging. If there are any pending test results that you have organised at the time of this referral please provide information including TYPE OF INVESTIGATION requested (bloods, imaging) and TRUST performing the tests in the box below.
CLINICALLY-SPECIFIC AUTOMATIC TABULATED DATA
IMAGING STUDIES (in past 3 months) Please include date: and location:
Pan London Suspected Children's Cancer Referral Form Page 4 of 4
(Version: Pan London changes SONI2; 13/01/2016)
Standard NHS Referral Form Layout & Artwork created by Dr Ian Rubenstein
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_Name»
RENAL FUNCTION (most recent recorded in past 3 months)
FBC (most recent recorded in past 3 months)
ESR (most recent recorded in past 3 months)
CRP (most recent recorded in past 3 months)
ROUTINE AUTOMATIC TABULATED DATA
RECENT PATHOLOGY RESULTS
«Recent_Pathology»
PROBLEMS
«Summary»
ALLERGIES
«Allergies»
MEDICATION
«Current_Repeat_Templates»
Pan London Suspected Children's Cancer Referral Form Page 4 of 4
(Version: Pan London changes SONI2; 13/01/2016)
Standard NHS Referral Form Layout & Artwork created by Dr Ian Rubenstein